The general, general surgeon

The general, general surgeon

THOMAS G. ORR MEMORIAL LECTURESHIP The General, General Surgeon Alden H. Harken, MD, Denver, Colorado I t is a tremendous honor for me to present t...

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THOMAS G. ORR MEMORIAL LECTURESHIP

The General, General Surgeon Alden H. Harken, MD, Denver, Colorado

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t is a tremendous honor for me to present the Thomas G. Orr Memorial Lecture at the Southwestern Surgical Congress this year. I am particularly grateful to President McCollum and his wife, Sally. Dr. Orr served with distinction as the chairman of the Department of Surgery at the University of Kansas and was the second president of the Southwestern Surgical Association. It occurs to me that Dr. Orr really personified all that is good about our discipline and our profession of general surgery. Dr. Orr was a consummate clinical surgeon. He exhibited the kind of compassion for his patients and their families that reflects great credit upon our discipline. He recognized his responsibility to give back to his community. And he was actively involved in training his successors and instilling within them the kind of rigorous self-criticism that is characteristic of general surgeons—the kind of continuous self-review that makes us perform better and better. In the next 45 minutes I propose to review with you: (a) who we are as general, general surgeons; (b) what our influence and opportunities are concerning the evolution of surgical instrumentation; (c) our responsibilities relative to continued quality assurance and self-review; (d) trends in our training of general surgeons and our responsibilities of maintaining a cohesive discipline of general, general surgery; and finally (e) our almost unique, and gratifying rewarding, opportunity as general surgeons to create sustaining value.

WHO ARE WE? Throughout the millennia, man has consistently been barraged with the perception of change. As physicians and surgeons we have, indeed, evolved. Change is ultimately progress and progress is ultimately good. Lewis Thomas has observed that the first time a patient could consult a physician with a likely beneficial result was approximately 1922. During the current century we have been privileged to observe and participate in an extraordinary period of scientific/medical/surgical progress. Indeed, much like the enlightenment thinkers of the 17th and 18th centuries, we currently believe in science. We believe that the more we understand about the mechanisms of biological processes, the more favorably we will be able to influence them therapeutically. Edward O. Wilson1 recently stated, “the Enlightenment got it mostly right.” And “The fragmenta-

Am J Surg. 1998;176:494 – 496. From the Department of Surgery, University of Colorado Health Sciences Center, Denver, Colorado. Requests for reprints should be addressed to Alden H. Harken, MD, Chairman, Department of Surgery (C-305), University of Colorado Health Sciences Center, 4200 East Ninth Avenue, Denver, Colorado 80262. Presented at the 50th Annual Meeting of the Southwestern Surgical Congress, San Antonio, Texas, April 19 –22, 1998.

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tion of knowledge and the chaos in philosophy are not reflections of the real world, but artifacts of scholarship.” Thus to continue Wilson’s thread, enlightenment thinkers (general surgeons) know a lot about everything, while today’s super-specialists know even more about very little. The general, general surgeon therefore performs a critically important and fundamentally constructive role in health care. Interestingly, critical review of health care indicates that it is: (1) a clean, nonpolluting industry; (2) the results are typically good; and (3) it provides employment. Within health care, however, surgeons have appropriately carved out a fundamentally important niche. Surgery is not specific to a skin incision. Indeed, surgeons are typically obligated to initiate therapy with the clock ticking. Many medical disciplines permit the rigorous characterization of a pathophysiological diagnosis prior to the initiation of therapy. This is not true of surgery. We, typically, must do something before we know what is going on. This means that we must tolerate error. In tolerating error, we are almost unique in our right to be wrong. When we are wrong, we must acknowledge our error. A surgical morbidity and mortality conference is typically different than any other discipline’s M&M process. Surgeons admit diagnostic, management, and technical errors. In almost all other medical disciplines, when a patient doesn’t do well, it’s always due to the patient’s disease. We surgeons must, and characteristically do, encompass the four standard components of medical ethics: (1) beneficence, the obligation to do good; (2) nonmalfeasance, the responsibility to do no harm; (3) autonomy, the recognition of a patient’s right to participate and direct his or her own therapy; and finally, (4) justice, the importance of relating a patient’s disease/therapy to his or her family and community. We surgeons must also accomplish these four principles with sensitivity and compassion. Interestingly, it is typically easier for us to accomplish this than it is for other medical specialists. Our patients want to trust us. However, the unique aspect of surgical diagnosis and therapy is our obligation to proceed before we are confident of the diagnosis. John Finley stated, “Maturity of mind is the capacity to endure uncertainty.” We surgeons tend to dive into the swamp and look around for alligators while our internist colleagues analyze the swamp water for its osmolality, acidity, and nutrient content to see if the water will support alligator life. We are plungers, they are planners; we are uncertain, they are certain; we require a deadline, they prefer a laissez-faire attitude. And we require the right to be wrong, while they aspire to perfection.

INSTRUMENTATION We surgeons think of ourselves as using tools to accomplish our therapeutic goals. The advent of minimalist surgery has permitted and promoted a gratifying and rewarding subspecialty within surgery. Through tiny ports, we can 0002-9610/98/$19.00 PII S0002-9610(98)00251-7

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now visualize anatomy and disease in a fashion that surprises most of us. Facile surgeons can now accomplish technical feats in a world of virtual reality that inflicts substantively less neurohormonal stress upon our surgical patients. As we progress and evolve from an appendectomy to a laparoscopic cholecystectomy to a vertical banded gastroplasty to a light-amplified Jabberwocky and to a Baltimore Gross-billed vandersnatchy we must be constantly vigilant in balancing real technological advance with laser amplified public relations. As health care has evolved, Americans have developed three concurrent expectations: (1) immediate access to (2) high tech medicine at (3) limited cost. Interestingly, it is possible to simultaneously accomplish any two of these three American expectations—it is not possible to have all three.

QUALITY ASSURANCE/SELF-REVIEW During the early phases of my surgical career, I was incredibly fortunate to work with two cardiac electrophysiologists, Mark Josephson and Leonard Horowitz. Mark and Lenny were young, enthusiastic cardiologists who, with relative frequency, encountered patients brought to our emergency department following an episode of ventricular fibrillation/sudden cardiac death. A capable City of Philadelphia paramedic team could expeditiously resuscitate these patients, bring them to the emergency department, at which time electrocardiography and enzyme analysis frequently indicated no new myocardial damage. There was, therefore, no real indication to admit the patient to the hospital. However, the patient had just had a maximally frightening “sudden cardiac death” event. Back in 1976, the standard therapy was to admit the patient for a couple of days, worry a lot, and then discharge the patient with the admonition “don’t let it happen again.” Mark and Lenny did not find this very reassuring. They both developed the idea that we might take these patients to the electrophysiology laboratory and induce stable, ventricular tachycardia. If ventricular tachycardia was inducible and could not be suppressed with antiarrhythmic medications, they proposed that we take these patients to the operating room and map out the origin of the aberrant electrical circuit.2 The idea was that I would then surgically excise this electrical circuit. At the time, no one had ever done this. We did not know that we could find the aberrant electrical tissue. We were not confident that I could ablate it, and we had no reason to believe that the scar resulting from the surgical excision would not be equally arrhythmogenic. In October of 1978, a patient was admitted to our hospital with ventricular tachycardia. In the subsequent week, he experienced six additional episodes of life-threatening ventricular tachyarrhythmias. I well remember explaining to him our therapeutic proposal. We talk a lot about surgical courage. Our patient demonstrated a whole new level of real courage when he said “go ahead.” We were extraordinarily fortunate, things went smoothly, and Mr. Andrews is still doing well as the vice president of a bank in New Jersey. In the next several years, we accomplished 30 more of these electrophysiologically directed surgical procedures. At that time, the medical community wanted us to initiate a prospective, randomized study of electrophysiologically directed surgical therapy versus standard medical antiar-

rhythmic therapy. After 30 surgically treated patients, we had experienced a 9% 30-day mortality. With standard medical antiarrhythmic therapy, 80% of patients succumbed in 1 year. We did not think it ethical to perform a prospective, randomized study. I, therefore, went back and looked at historical controls. In the 19 patients I had operated on in the previous years for recurrent sustained ventricular tachycardia (I had excised infarct scar and revascularized patients), I had experienced a 42% 30-day mortality! And, almost 80% of these patients still had inducible ventricular tachycardia following surgery. I was horrified! I knew we weren’t doing very well; however, I thought this was a particularly sick group of patients and with constructive editorialization of my memory I was able to assuage my conscience. In reality, our surgical results had been terrible. But I had not previously looked. This was my first recognition of a surgeon’s obligation to review his/her own patient results in his/her own hospital. Quality assurance/self-review is an obligate part of our high-profile specialty.

TRENDS We surgeons have been extraordinarily responsible concerning our own “birth control.” In the past 2 decades, the number of anesthesiologists certified by the American Board of Anesthesiology has more than tripled. The number of internists certified by the American Board of Internal Medicine has more than doubled. The number of pediatricians certified by the American Board of Pediatrics has doubled. And the number of surgeons certified by the American Board of Surgery has actually decreased! From 1,018 in 1979 to 997 in 1996. Several years ago, the Council on Graduate Medical Education predicted that there would be an 11% deficit of general surgeons by the year 2000. Specialization within internal medicine has grown wildly out of control. In the past 2 decades, the number of cardiologists has increased by almost 2000%, while the number of gastroenterologists has increased by almost 4000%. Perhaps predictably, the American Board of Internal Medicine has not asked me for my advice. Conversely, I believe our internists colleagues are now superspecializing their trainees to perform a kind of medicine that they will never actually be able to practice. The glorious aspect of running a surgical training program is the enthusiastic manner in which all of our trainees are eagerly recruited into multiple different varieties of practice opportunities each year. A darker cloud within general surgery, however, is the further fragmentation of general, general surgery. After finishing our training, many of us have gravitated into a somewhat specialized field within general surgery—my own focus is hearts—and within cardiac surgery, I even practice (although not exclusively) the surgical therapy of the cardiac conduction system. But I certainly consider myself a general, general surgeon. The highlight of my personal practice is the four times each week that I meet with our residents in the Surgical Intensive Care Unit to discuss issues spanning the general surgical spectrum from colorectal cancer to aortoiliac disease to pancreatitis to multiple organ failure. Again, in order to effectively represent the glorious field of general, general surgery, I personally deplore disciplinary fragmentation into critical care surgery,

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colorectal surgery, vascular surgery, surgical nutrition, and trauma surgery. Although each one of these subspecialties is arguably a gratifying, rewarding, and fun discipline within general surgery, I believe our patients, trainees and colleagues will all be better off if we recognize and build upon on our similarities rather than focusing on our differences. Indeed, as I indicated at the beginning of this lecture, surgery is not specific to a skin incision: It is a mindset that permits an active rather than passive approach to therapy prior to nailing down the diagnosis.

CREATE SUSTAINABLE VALUE We, general surgeons, are different. As we relate to our medical colleagues, nurses, and hospital administrators we must also acknowledge our obligation to participate in the development of programs within our hospitals. Thoughtful and diplomatic hospital administrators acknowledge the necessity to achieve consensus and, therefore, feel obligated to notify both internists and surgeons concerning upcoming programmatic/planning meetings. Typically, however, the hospital director knows whether Internist X

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or Surgeon Y is going to create a problem at that meeting. A scheduling strategy has, therefore, philosophically been developed in almost all of our hospitals. We must raise this scheduling strategy to a level of our own consciousness: To schedule a meeting to exclude the internist, schedule it “tomorrow at 7:00 a.m.” To schedule a meeting to exclude the surgeon, schedule it “at noon in a month.” Ultimately, surgical participation in all aspects of hospital affairs is to the huge advantage of our patients, our programs, our hospitals, and ourselves. Thoughtful surgical participation is not an impossible dream. If the galaxy is where you happen to live, the most gratifying, rewarding, and fun profession you can possibly attain is to be a general, general surgeon. I am proud to be a general, general surgeon.

REFERENCES 1. Wilson EO. Back from chaos. Atlantic Monthly. March 1998; 281(3). 2. Harken AH. Surgical treatment of cardiac arrhythmias. Sci Am. 1993;269:68 –74.

THE AMERICAN JOURNAL OF SURGERY® VOLUME 176 DECEMBER 1998